With the full implementation of the Affordable Care Act, the share of adults in New York City without health insurance dropped from 20.9 percent in 2013 to 13.8 percent in 2014, a 7.1 percentage point decline. To gauge the effect on New York City Health + Hospitals, we focus on adult outpatient visits to H + H hospitals and diagnostic and treatment centers because some conditions that require inpatient stays, such as medical emergencies, allow for temporary Medicaid eligibility.

Although the city’s public hospital system saw a reduction in the share of outpatient visits by uninsured adults, the decline was less steep—4.0 percentage points—than the city as a whole.

In 2015, the share of H + H’s outpatient visits by uninsured adults (25.2 percent) was 11.4 percentage points greater than the share of uninsured adults in the general population.

For both the city’s population and H + H’s patients, those adults who gained health insurance did so through Medicaid or commercial insurance in approximately equal proportions.

Both the share of adult outpatient visits by uninsured patients and the impact of the Affordable Care Act on this share vary widely across H + H facilities.

The hospital centers serving the largest shares of adult outpatients who are uninsured include Elmhurst, Queens, Bellevue, and Woodhull.

Although each of these four hospital centers saw declines in the share of adults without insurance from 2013 through 2015, all of the decreases fell short of the reduction in the share of uninsured for the city as a whole. Woodhull saw by far the smallest decline, 1.8 percentage points.

SOURCES Department of Health & Mental Hygiene, New York City Community Health Survey, 2014. Health & Hospital Corporation Payor Mix Reports, September 2015 and September 2014, as reported to the Finance Committee.
NOTES: For the share of outpatient visits by uninsured adults at H + H facilities, pre-Affordable Care Act reflects fiscal year 2013 and post-Affordable Care Act reflects fiscal year 2015. For the share of New York City adults who are uninsured, pre-Affordable Care Act reflects calendar year 2013 and post Affordable Care Act reflect calendar year 2014, as reported by the Department of Health and Mental Hygiene Community Health Survey for those years. Coney Island Hospital is not included in the chart breaking out visits by facility because Hurricane Sandy had a lasting impact on the number of visits the hospital was able to provide in 2013 and 2014.

Under federal and state law, families with young children receiving cash assistance and participating in work or training programs are guaranteed vouchers to pay for their choice of child care providers. A limited number of vouchers are also available to low-income working families. As the de Blasio Administration moved to vastly expand the number of full-day pre-kindergarten slots available for the city’s children, many expected that there would be a corresponding decline in the use of child care vouchers for 4-year-olds.

From October 2013 through October 2015 the number of children enrolled in full-day pre-k more than tripled, rising from 19,490 to 69,090.

Over the same period, the use of of full-time vouchers for the care of 4-year-olds fell. For the children of cash assistance families the decrease was only 9.5 percent, from 6,128 to 5,549.

For children in low-income families the number fell by 23.3 percent, from 1,395 to 1,070.

Together, these changes mean that as of fall 2015, 6,619 children were still in voucher-funded full-time child care rather than Department of Education pre-k classes.

The relatively small number of 4-year-olds in part-time voucher child care increased over the two years by 36.9 percent, from 279 to 382. It is possible that many of them were attending pre-k classes and using the vouchers for after-school care.

Parents who use child care vouchers can choose among a wide variety of child care providers including informal care, family child care, and center-based care. Not all of these providers offer the educational elements available to children enrolled in the Department of Education’s pre-k programs.

SOURCES: Department of Education; Administration for Children’s Services
NOTES: Pre-k enrollment is as of October of each year. The voucher numbers for school years 2013-2014 and 2014-2015 are averages for September through June. The voucher numbers for 2015-2016 are averages for September through December.

In October 2014, the city’s Human Resources Administration announced a new employment plan for public assistance recipients. The plan, which was already being phased in before the formal announcement, makes the agency’s employment programs less punitive and puts more emphasis on education and training. Some of the changes can already be seen by comparing participation data from December 2013 with December 2014.

Share of Caseload in Various Work Participation and Preparation Classifications

The number cash assistance cases under or facing sanctions for violating the employment requirements fell from 19,632 (19.6 percent of all cases) to 14,473 (13.6 percent).

Cases with the household head in an education, training ,or job search program increased from 3,347 (3.3 percent) to 5,485 (5.1 percent).

The number of cases classified as temporarily unengageable jumped from 9,119 (9.1 percent) to 19,823 (18.6 percent), primarily due to a big increase in the number of cases being evaluated for WeCARE, a program designed to help clients overcome medical and/or mental health barriers to employment.

The number participants in the long controversial Work Experience Program, which requires participants to work for their cash and food stamp benefits, also decreased somewhat from 10,661 (10.6 percent) to 9,786 (9.2 percent). The plan calls for gradually phasing out this program.

Prepared by Paul LopattoNew York City Independent Budget Office

SOURCE: Human Resources Administration, Weekly Caseload Engagement Status Reports for January 5, 2014 and January 4, 2015
NOTES: The numbers exclude cases categorized as indefinitely unengageable including child only cases, and those in which the household head is receiving Supplemental Security Income, is age 60 or over, or is receiving services from the HIV/AIDS Services Administration. They also exclude a small number of cases categorized as unengaged. Cases are classified by their primary activity.

More than half (51.3 percent) of the state’s lowest income part-time workers—those with incomes at or below 200 percent of the federal poverty level—resided in New York City in 2012.

A greater reliance on Medicaid among New York City’s lowest income part-time workers may be linked to their lower rate of enrollment in employer-sponsored health insurance compared with the rest of the state.

A smaller share of low-income, part-time workers was uninsured in the city than in the downstate suburbs. But an even smaller share of these workers was uninsured upstate, where the rate of enrollment in employer-sponsored health insurance was highest in the state.

SOURCE: American Community Survey Public Use Microdata Sample 2012
NOTES: Percentages do not sum to 100. Direct purchase insurance and Medicare are excluded, and individuals may have both employer-sponsored health insurance and Medicaid. The federal poverty level for a family of four in 2012 was about $23,500.

From June 2006 through June 2013, the number of New York City residents receiving food stamps (now known as the Supplemental Nutrition Assistance Program, or SNAP) increased by 71.1 percent, from 1.1 million to 1.9 million. From June 2013 through June 2014, however, the number of recipients fell by 118,000, or 6.3 percent.

Recent decreases in the number of food stamp recipients likely reflect improvements in the local labor market.
Nationwide, over the same June 2013-June 2014 period, the number of individuals receiving food stamps fell by a more modest 2.6 percent.

As a result of the decreased caseload as well as federal reductions in per family grant payments beginning in November 2013, total food stamp grants to city residents decreased by $244 million, or 6.9 percent, from fiscal year 2013 to 2014.

Prepared by Paul LopattoNew York City Independent Budget Office

SOURCES: IBO analysis of data from the New York City Human Resources Administration, the New York State Office of Temporary and Disability Assistance, and the United States Department of Agriculture

Over the last decade, the number of city residents receiving food stamps has more than doubled, while public assistance recipients have decreased and the number of blind and disabled New Yorkers receiving Supplemental Security Income benefits has remained flat.

SOURCES: New York City Human Resources Administration; New York State Office of Temporary and Disability Assistance
NOTE: Public assistance and Supplemental Security Income recipients may also receive food stamps.